GENERAL PURPOSE: The Claims Specialist serves Medicare, Medicaid and commercial insurance customers by determining insurance coverage; examining and resolving Medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Responsible for processing healthcare claims in accordance with production, timeliness and quality standards.
- Participates with other health plan departments in the resolution of claims issues across department lines.
- Ensures claims are processed in compliance with governmental and accrediting agency regulations.
- Ensures the delivery of superior customer services by providing timely and accurate claims payment and responding timely to member and provider inquiries and complaints regarding claims processing.
- Develops strong intradepartmental relationships with other department personnel and/or exempt individual contributors to ensure clear communication and prompt resolution to issues.
- Follows departmental policies and procedures regarding claims adjudication.
- Ensures that potential fraudulent claims practices are identified and reported to the appropriate compliance department.
- Follows all HIPAA compliance guidelines to ensure protection of member protected health information.
- Performs other duties as assigned.
QUALIFICATIONS AND REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED) required; minimum two years experience in managed care claims processing environment required; experience with the internal configuration of claim processing systems and the links between contracts, utilization management and claims processing within these systems required; or an equivalent combination of education, training and experience.